| NPI | 1699383166 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD5371) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901022783) |
| Enumeration Date | 2020-07-21 |
| Last Update Date | 2023-11-04 |